Utah Medicaid Pharmacist DHHS

State of Utah Office of the Governor•Salt Lake City, UT

12d•$43 - $64•Hybrid

About The Position

This position supports the development, implementation, and oversight of pharmacy coverage policy and prior authorization programs for Utah Medicaid. The role involves reviewing and developing coverage policies, creating and maintaining clinical prior authorization criteria, evaluating prior authorization requests to ensure alignment with clinical guidelines and program requirements, and participating in clinical programs to ensure Medicaid members have access to safe, effective, and appropriate medications. The position is hybrid, with two days in-office and three remote work days, and requires the employee to reside in Utah.

Requirements

Must reside in Utah and be available to work in-office on Mondays and Tuesdays.
Must hold a current and active pharmacist license in good standing in the State of Utah.
Knowledge of pharmacotherapy, clinical pharmacy practice, and evidence-based treatment guidelines.
Experience evaluating clinical literature, treatment guidelines, and drug information.
Ability to review clinical information and apply established criteria to determine medical necessity and medication coverage.
Strong written and verbal communication skills, including clearly communicating clinical determinations to providers and stakeholders.
Ability to organize and document clinical information to maintain accurate and compliant records.
Experience working in a team environment and managing multiple priorities in a fast-paced setting.
Must successfully pass a DHHS background check.

Nice To Haves

Experience working with Medicaid pharmacy programs or other public health programs.
Experience developing or maintaining pharmacy coverage policies or clinical prior authorization criteria.
Experience reviewing prior authorization requests or performing clinical case reviews.
Knowledge of Drug Utilization Review (DUR) processes and provider outreach programs.
Experience analyzing pharmacy or medical claims data to identify trends or opportunities for program improvement.
Familiarity with Preferred Drug Lists (PDL) and pharmacy benefit management processes.

Responsibilities

Develop, implement, and maintain pharmacy coverage policies and clinical prior authorization criteria.
Review and evaluate prior authorization requests for clinical appropriateness and necessity.
Perform comprehensive clinical reviews by evaluating patient information against established policy criteria, clinical guidelines, and evidence-based recommendations.
Evaluate and interpret clinical literature, treatment guidelines, and emerging evidence to support policy and coverage decisions.
Analyze pharmacy and medical claims data to identify trends and opportunities to improve the Medicaid pharmacy program.
Participate in clinical programs such as Drug Utilization Review (DUR), provider outreach, and peer-to-peer education.
Communicate prior authorization determinations clearly and professionally to providers and members.
Collaborate with internal teams and contribute to workgroups to support program initiatives and process improvements.
Maintain accurate documentation of reviews, decisions, and supporting information to ensure a complete and compliant audit trail.
Contribute to process improvement efforts by identifying opportunities to streamline workflows and enhance program effectiveness.
Support assigned projects and initiatives within established timelines.
Remain current on clinical information, drug therapies, and Medicaid pharmacy program requirements.
Triage incoming phone calls from providers specific to prior authorization decisions.
Perform other related duties as assigned.